Christian Basketball League Medical Release

Player: ________________________________________ Parent or Guardian Authorization: In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician) Family Physician: __________________________________ Phone: ______________________ Address: ______________________________________________________________________ Hospital Preference: ____________________________________________________________ In case of emergency contact: D.O.B. ________________________

Name

Phone

Relationship to Player

Name

Phone

Relationship to Player

Please list any allergies/medical problems, including those requiring maintenance medications. (i.e. Diabetic, Asthma, Seizure Disorder)

Medical Diagnosis

Medication

Dosage

Frequency of Dosage

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. Date of last Tetanus Toxoid Booster: _______________________________________________

Authorized Parent/Guardian Signature

Date